Should I replace my "lost" hormones?
It’s a question that many women entering the menopause transition ask themselves as they cope with their body’s decline in estrogen and progesterone—and the symptoms that often come along with it: hot flashes, night sweats, problems sleeping (and related mood issues), vaginal dryness and pain and urinary tract infections.
Hormone replacement therapy is an incredibly effective way to ease symptoms, and it can make the transition a lot less disruptive to your life. It’s also been shown to protect against osteoporosis and bone fractures. But if you’re considering hormone therapy, you’ve probably heard that it’s also been associated with an increased risk of certain diseases. Because there are both pros and cons to this treatment, it’s especially important to educate yourself about it before making a decision.
Getting to Know the Research
There’s been a lot of back-and-forth in the medical community about hormone replacement therapy, and that confusion stems from contradictory studies. Before an important trial called the Women’s Health Initiative (WHI), studies showed that hormone therapy eased menopause symptoms and protected against heart disease, bone fractures due to osteoporosis and cancer. Based on these early studies, doctors prescribed hormone therapy to nearly all menopausal women, not just to reduce symptoms like hot flashes and night sweats, but also to prevent these diseases. Sometimes hormones were prescribed primarily for disease prevention.
Then came the WHI, a landmark study begun in 1991 that looked at more than 160,000 women. The trial was stopped several years early when it was found that women who took hormones were more likely to have heart attacks and strokes and develop blood clots and breast cancer, and that these risks outweighed the benefits. Other research has suggested that hormone therapy may increase the risk of ovarian cancer as well. Based on these studies, doctors immediately started shifting away from prescribing hormone therapy, says Cindy Geyer, M.D., medical director at Canyon Ranch in Lenox, Mass.: “Many women threw out their hormones, were told that risks outweight benefits and were left wondering how to manage symptoms.”
Since then, though, experts have taken a much closer look at the Women’s Health Initiative and how it was conducted. First, there was the age of the women who were studied. The average age of menopause is 51 and the early studies that showed benefits of hormone therapy looked at women around this age. In the WHI, though, the average age of the women was 64, by which time hardening of the arteries has often already begun. Estrogen protects against the build-up of plaque in the arteries, but once hardening of the arteries is set in motion the hormone appears to have the opposite effect—accelerating the onset of heart attacks.
The type of hormones used in the WHI and the way they were given to participants also raised concerns. The most commonly used combination at the time was estrogen made from pregnant mares’ urine and progestin, a synthetic hormone similar to progesterone; that’s what the WHI studied. Both hormones were given by mouth and are processed by the liver. When the liver breaks down this form of estrogen, several factors that play a role in heart disease (triglycerides, clotting factors, C-reactive protein and blood pressure) can increase. “The arguments against this study say that they used the wrong age group of women, the wrong route of administration and a form of hormones that is biochemically different than what women naturally produce,” Dr. Geyer explains.
In a more recent trial, the four-year Kronos Early Estrogen Prevention Study (KEEPS), women within three years of their last period received bioidentical estradiol through skin patches combined with oral progesterone. “The trial was very effective for symptom relief and they did not see higher rates of heart disease or breast cancer,” Dr. Geyer says. In fact, women at high risk of heart disease appeared to get some protection from the therapy.
Making the Right Choice for You
Today, hormone replacement is no longer prescribed primarily for preventing disease. But many doctors feel that combined hormone therapy with estrogen administered through the skin—where it bypasses the liver—appears to be safe if started early and used for less than five years for the treatment of menopause symptoms. “There’s a critical window,” Dr. Geyer says. “If you introduce hormones soon enough after your last period, you’re less likely to have the downsides. But if you wait until 10 years postmenopause, you may cause more problems than you help.” The Food and Drug Administration recommends that hormone therapy be used at the lowest doses for the shortest amount of time needed to reduce symptoms. Dr. Geyer recommends using bioidentical hormones because they have a lower likelihood of adverse effects such as increased clotting and decreased artery elasticity. “It’s also possible to measure levels of estrogens and progesterone in women using bioidentical hormones, which can better guide treatment,” Dr. Geyer says.
You can take estrogen alone if you’ve had a hysterectomy (the removal of your uterus); otherwise, doctors recommend a combination of estrogen and progesterone to protect against uterine cancer. Taking progesterone alone may be suggested for you, particularly if you can't opt for estrogen because of your medical history. However, long-term safety is not clear, so it is best not to continue use after menopause.
“Often women have a mismatch of higher estrogen and lower progesterone in perimenopause, and this can help,” Dr. Geyer says. In one study, progesterone reduced the frequency and severity of hot flashes by 56 percent, with no increased risk of heart disease. If you’re mainly concerned about vaginal symptoms, low-dose vaginal estrogen and vaginal DHEA (a hormone that leads to the production of sex hormones) can provide relief; a small subset of women may experience raised levels of estrogen in their blood when using this therapy, however. If you have been treated for an estrogen-positive breast cancer, it is important to discuss vaginal estrogen with your oncologist.
Keep in mind that although short-term hormone replacement appears to be safe in most women, your case may be different. Having a conversation with your doctor can help you identify your individual risks. Before you start hormone replacement, for example, your doctor should check your bone density. “A very high bone density may be a surrogate marker for someone who’s at a higher-than-average risk of breast cancer, in which case hormones might not be recommended,” Dr. Geyer says. If your doctor has a one-size-fits-all approach to hormone replacement that doesn’t consider your health history, status and concerns, you might want to have the discussion with another physician. “You need to weigh risks and benefits and figure out what makes the most sense for you at this point in time,” Dr. Geyer says. “And because of that, it’s important to have somebody who you can dialogue with and follow up.”
Depending on how bothersome your symptoms are, and whether you have risk factors, your internist or gynecologist might be able to suggest a different route for you. For example, because hormones influence each other, balancing your thyroid hormones, DHEA, insulin, cortisol and vitamin D (which acts like a hormone), can help your body adjust to changes in your estrogen and progesterone levels. And natural remedies, like eating more low-glycemic whole foods to regulate your blood sugar, cutting out personal dietary triggers such as coffee or alcohol, practicing deep breathing and taking botanical supplements, might also bring you some relief. Visit our article, Natural Remedies for Menopause Symptoms, to learn more about these options.
Throughout your process, remember that the best choice is the one that makes sense for you: “A personalized approach tailored to your symptoms, your risk factors and your response to different modalities offers you the opportunity to find the best path for your health and well-being,” Dr. Geyer says.